e quijada - im symposium sept 2017 - approved - 9-1-17 · 9/12/2017 1 palliative careupdate:...

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Palliative Care Update: Dementia, Delirium, DeprescribingEarl Quijada, MD FAAHPMSeptember 15, 2017

60th Annual Raymond M. Kay, MD Internal Medicine Symposium

Objectives

•Understand the importance of prognostication

•Gain a different perspective on quantity of life vs. quality of life

• Know four points to build a framework of care

• Practice complex reflection


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Core idea

• Build rapport•Gather information


Framework

• Identify patient• Estimate prognosis

•Define goal• Value

• Plan of care• “Strong opinions, lightly held”


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Quantity vs Quality

•Quantity• Fear of abandonment• Fear of unknown

•Quality• Fear of pain


Value = Quality / Cost


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Mrs. C. is an 85‐year‐old widowed homemaker with Alzheimer's disease who was recently admitted to a nursing home following a hip fracture three months ago. That event was complicated by delirium and a congestive heart failure (CHF) exacerbation. Her ejection fraction showed moderate systolic dysfunction (35%). She also has hypertension, osteoporosis, and asymptomatic coronary artery disease. Although no longer able to walk, she has fairly preserved language skills and can assist with transfers and most activities of daily living. She does not have the capacity to discuss most of the medical treatment decisions, and defers to her daughter as her surrogate. She has lost 20 lbs. over the last two years (10 lb. in the last year) and weighs 174 lbs. Her daughter thinks her mother is nearing the end of life and asks whether her mother is eligible for hospice

Your next step in management is:

1. Refer to hospice2. Prescribe an appetite stimulant3. Review the POLST form4. Discuss prognosis5. Remind daughter, only one problem per visit

Jayes RL, Arnold RM, Fromme EK. Does this dementia patient meet the prognosiseligibility requirements for hospice enrollment? J Pain Symptom Manage 2012;44:750‐6.


An 89‐year‐old male nursing home resident with a 10‐year history of Alzheimer’s disease presents with a temperature of 37.8°C, a productive cough, and a respiratory rate of 24 breaths per minute. Nurses report that for the past 6 months he has been coughing at breakfast and having trouble swallowing. He has profound memory deficits, no longer recognizes his daughter (who is his health care proxy), is bed bound, is able to mumble a couple of words, and is unable to perform any activities of daily living.


1. Refer to hospice2. Start oral antibiotics3. Review the POLST form4. Discuss prognosis5. Send to emergency department

Mitchell SL. Advanced Dementia. N Engl J Med. 2015 Sep 24;373(13):1276‐7


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Primary hospice diagnosis, no. (%)

National hospice SCPMG

Cancer 10,883 (33.4%) 3,177 (52.5%)

Cardiovascular 3,656 (11.2%) 672 (11.1%)

Cerebrovascular 2,878 (8.8%) 145 (2.4%)

Dementia 6,721 (20.6%) 569 (9.4%)

Unroe KT, Bernard B, Stump TE, Tu W1, Callahan CM.Variation in Hospice Services by Location of Care: Nursing Home Versus Assisted Living Facility Versus Home. J Am Geriatr Soc. 2017 Jul;65(7):1490‐1496.

SCPMG internal data


Invalid Principal Diagnosis (August 22, 2014)

•Dementia, unspecified, with behavioral disturbance• Vascular dementia• Frontal lobe syndrome•Debility• Failure to thrive

CMS Manual CR 8877 https://www.cms.gov/Regulations‐and‐Guidance/Guidance/Transmittals/Downloads/R3032CP.pdf


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Valid Principal Diagnosis

• Alzheimer’s dementia

• Lewy body dementia

• Parkinson’s dementia


Alzheimer’s Hospice Guideline

FAST 7 or above Aspiration pneumonia or

Unable to walk without assist Pyelonephritis or

Unable to dress without assist Sepsis or

Urinary and fecal incontinence Multiple ulcers or

No meaningful conversation; < 6 words

Recurrent fever after antibiotics or

PLUS within 12 months>10% wt loss, serum albumin < 2.5 g/dl

Local Coverage Determination (LCD) for HOSPICE - Determining Terminal Status (L25678)


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Functional Assessment Staging (FAST)

Stage Check highest consecutive level of disability

7a Speaks less than 6 intelligible words

7b Single intelligible word

7c Ambulatory ability lost*

7d Cannot sit up without assistance

7e Loss of ability to smile

Reisberg B. Functional Assessment Staging (FAST). Psychopharmacol Bull. 1988;24(4):653‐659


Alzheimer’s Hospice Guideline

•Not evidenced based• Common for patients that don’t meet guideline to die within 6 months

Fox E., Landrum‐McNiff K., Zhong Z., et al: Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart, or liver disease. J Am Med Assoc 1999; 282: pp. 1638‐1645

Mitchell S.L., Teno J.M., Kiely D.K., et al: The clinical course of advanced dementia. N Engl J Med 2009; 361: pp. 1529‐1538


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Mitchell / Advanced Dementia Prognostic Tool (ADEPT)•https://eprognosis.ucsf.edu/mitchell.php

Mitchell SL1, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffer ML. Prediction of 6‐month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. 2010 Nov 3;304(17):1929‐35.


LCD Guidelines vs ADEPT

LCD ADEPT

Ability to predict 6 month mortality 0.55 0.67

Mitchell SL1, Miller SC, Teno JM, Kiely DK, Davis RB, Shaffer ML. Prediction of 6‐month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA. 2010 Nov 3;304(17):1929‐35.


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Prognostic clues

•Median survival for NH home patients was 1.3 years

•End stage dementia with pneumonia 53% 6‐month mortality

•End stage dementia with hip‐fracture 55% 6 month mortality

Mitchell S.L., Teno J.M., Kiely D.K., et al: The clinical course of advanced dementia. N Engl J Med 2009; 361: pp. 1529‐1538

Morrison RS, Siu AL. Survival in end stage dementia following acute illness. JAMA 2000;284:47‐52


Discussing prognosis

ADAPT

Ask What have the doctors told you?

Discover Is it ok to talk about the future? What plans do you have?

Anticipate ambivalence

Talking about the future can be scary

Provide infoFrom my knowledge of the situation, this is what we’re looking at…

Track emotion I wish I had better news..

VitalTalk 2017


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A 78‐year‐old male living at home with a 10‐year history of Alzheimer’s disease presents with weakness. Daughter (who is health care proxy) reports for 6 months he has been coughing at breakfast and having trouble swallowing. He has lost 10# in 4 months (>10% wt loss). He used to walk up to 25 ft with a walker now he one person assist to walk 10 ft. He has profound memory deficits, no longer recognizes his daughter, is able to mumble a couple of words, and is unable to perform any activities of daily living.

His daughter understands his prognosis is poor and states that he wouldn’t want an attempted resuscitation if his heart stopped but she is asking if tube feeding would extend his life.


1. Refer to hospice2. Recommend tube feedings3. Review the POLST form4. Send to emergency department5. Offer comfort care


Clinical course of advanced dementia•Eating problems (86%)•Febrile episodes (53%)•Pneumonia (41%)

•Last 3 months of life (40.7%) burdensome intervention

•Mortality after 18 months (54.8%) N=323

Mitchell SL, Teno JM, Kiely DK, et al.The clinical course of advanced dementia. N Engl J Med 2009;361:1529‐38


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Tube feeding

Advanced dementia, requiring assistance with feeds

N=36492 Median survival 177 days

TF 1957 (5.4%)

Insertion at 1 month

Insertion at 4 months

No change in length of survival

Teno JM, Gozalo PL, Mitchell SL, et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc 2012;60:1918‐21.


Tube feeding

•Age and serum albumin related to 30d mortality

•Dementia and presence of PEG‐related complications not related to 30d mortality

•High‐calorie supplements, oral feedings help gain weight. No survival difference

Gaines DI1, Durkalski V, Patel A, DeLegge MH. Dementia and cognitive impairment are not associated with earlier mortality after percutaneous endoscopic gastrostomy. JPEN J Parenter Enteral Nutr. 2009 Jan‐Feb;33(1):62‐6.

Hanson LC, Ersek M, Gilliam R, Carey TS. Oral feeding options for people with dementia: A systematic review. J Am Geriatr Soc. 2011;59(3):463‐472


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Tube feeding

•No conclusive evidence of prolonging survival•No conclusive evidence of improving quality of life,

• It may actually increase the risk of developing pneumonia due to inhaling small quantities of the feed and even death.

Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009


Discussing tube feedings

PAUSE

Pause Pause, make time

Ask Ask. What’s important? What’s most difficult?

Understand Can you help me understand?

Suggest From what I know, this is what I would suggest

EmpathyI can see… ; It sounds like… ; This helps me understand, is this correct?

VitalTalk 2017


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A 78‐year‐old male living at nursing home with a 10‐year history of Alzheimer’s disease presents with weakness. Daughter (who is health care proxy) reports for 6 months he has been coughing at breakfast and having trouble swallowing. He has lost 10# in 4 months (>10% wt loss). He used to walk up to 25 ft with a walker now he one person assist to walk 10 ft. He has profound memory deficits, no longer recognizes his daughter, is able to mumble a couple of words, and is unable to perform any activities of daily living.

His daughter understands his prognosis is poor and states that he wouldn’t want an attempted resuscitation if his heart stopped but she is asking if antibiotics be helpful


1. Refer to hospice2. Offer antibiotics3. Review the POLST form4. Send to emergency department5. Offer comfort care


Clinical course of advanced dementia•Eating problems (86%)

•Febrile episodes (53%)•Pneumonia (41%)•Last 3 months of life (40.7%) burdensome intervention

•Mortality after 18 months (54.8%) N=323

Mitchell SL, Teno JM, Kiely DK, et al.The clinical course of advanced dementia. N Engl J Med 2009;361:1529‐38


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Antibiotics

•12‐months 2/3 of patients have suspected infection•72% treated with antimicrobials•94.8% wanted “comfort”•37.8% received counseling

Mitchell SL, Shaffer ML, Loeb MB, et al. Infection management and multi drug resistant organisms in nursing home residents with advanced dementia. JAMA Intern Med 2014;174:1660‐7


Antibiotics

•Primary outcome: survival vs symptom management

•Suspected pneumonia N = 225•91% received antibiotics•all that received antibiotics improved survival•all that received antibiotics had worse symptoms

Givens JL, Jones RN, Shaffer ML,Kiely DK, Mitchell SL. Survival and comfort after treatment of pneumonia in advanced dementia. Arch Intern Med 2010;170:1102‐7


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Wordsmatter

Phrases to avoid

Stop “What are your goals”

Stop “It’s time for hospice”

Stop “Do you want comfort care”

Stop “He’ll probably die on the table”

Stop “There’s nothing more we can do”

http://www.geripal.org/2010/03/maintaining‐relationships‐stop‐using_09.html


Value

•What’s most important to you?

•What’s the most difficult for you?

Contextualized with prognosis

Childers JW1, Back AL1, Tulsky JA1, Arnold RMJ REMAP: A Framework for Goals of Care Conversations. Oncol Pract. 2017 Apr 26


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Complex reflection

Vitaltalk


An 89‐year‐old male receiving hospice support at home for Alzheimer’s disease presents with tachycardia and dark concentrated urine. His son understands his prognosis is poor and hope patient can remain home. He was started on oral antibiotics for presumed urinary tract infection but he has not improved.

The patient reaches in the air and and tries to climb out of bed.

The resident you’re working gives report and asks if he should prescribe risperidone or haloperidol.


1. Smile,your resident isn’t recommending lorazepam2. Suggest risperidone3. Suggest haloperidol4. Suggest lorazepam5. Suggest non‐pharmacological therapy


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risperidone vs haloperidol

• Double‐blind, parallel‐arm, randomized clinical trial

• Oral risperidone vs. haloperidol vs. placebo

• Administered every 12 hours for 72h hours based on symptoms

• Supportive care

• Midazolam for severe distress or safety

Agar MR, Lawlor PG, Quinn S, Draper B, Caplan GA, Rowett D, Sanderson C, Hardy J, Le B, Eckermann S, McCaffrey N, Devilee L, Fazekas B, Hill M, Currow DC. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative CareARandomized Clinical Trial. AMA Intern Med. 2017;177(1):34‐42


risperidone vs haloperidol

Agar MR, Lawlor PG, Quinn S, Draper B, Caplan GA, Rowett D, Sanderson C, Hardy J, Le B, Eckermann S, McCaffrey N, Devilee L, Fazekas B, Hill M, Currow DC. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative CareA Randomized Clinical Trial. AMA Intern Med. 2017;177(1):34‐42

247

81haloperidol

82risperidone

84placebo

(slight worsedelirium score compared to placebo)

(slight worsedelirium score compared to

placebo)

more EPS more EPS less EPS

29% more likely to die

73% more likely to die


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haloperidol + lorazepam

RASS change

lorazepam + haldol

Placebo + haldol

Difference P value

0 to 30 min ‐3.62 ‐1.62 ‐2.00 <0.001

0 to 8 hours ‐4.12 ‐2.27 ‐1.85 <0.001

Hui, David. Lorazepam as an adjuvant to haloperidol for agitated delirium at the end of life: A double‐blind randomized controlled trial. 2017 ASCO Annual Meeting. Presented June, 2017


Polypharmacy

• 1 in 4 older patients hospitalized for medication related problems

• 30 ‐ 50% of hospitalizations potentially reversible• 18% of deaths attributable to Adverse drug reaction• 44% of patients discharged with unnecessary drug

Scott IA, et al. Deciding when to stop: towards evidence‐based deprescribing of drugs in older populations. Evid Based Med. 2013 Aug;18(4):121‐4.


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Drivers of polypharmacy

•Disease specific guidelines•Guideline derived quality indicators, performance incentives

• Sensitivity of age discrimination

• Focus on treating acute disease• Adverse drug effect seen as new diease

Scott IA, et al. Deciding when to stop: towards evidence‐based deprescribing of drugs in older populations. Evid Based Med. 2013 Aug;18(4):121‐4.


Tool for identifying and discontinuing potentially inappropriate drugs.

Ian A Scott et al. Evid Based Med 2013;18:121-124

©2013 by BMJ Publishing Group Ltd


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Deprescribing

•Pubmed “deprescribing” ‐> 219 items

•2007 ‐ 2013 ‐> 17 items

•2014 ‐ 2017 ‐> 202 items


Deprescribing

• Identifying and discontinuing drugs when harms outweigh benefit

•Patient centered but with inherent uncertainties

•Shared decision making

•May be misconstrued as limiting therapy

Scott IA et al, Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015 May;175(5):827‐34


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Process of deprescribing

• Is the patient actually taking the drug•Does the drug fit with the patient’s circumstances

•Does the benefit outweigh the potential harm•May be misconstrued as limiting therapy



Barriers of deprescribing

•Fragmented care, incomplete information

•Stopping a medicine that is in a clinical guideline

•Uncertainty of future•Emotional connection



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Medicines patient’s like

•Warfarin

• Insulins•Anti‐platelet agents•Oral hypoglycemic

•Opioids•Antibiotics


Most common hospitalization for adverse drug event•Warfarin

• Insulins•Anti‐platelet agents•Oral hypoglycemic

•Opioids•Antibiotics

Budnitz, DS et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N Engl J Med 2011; 365:2002‐2012


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Warfarin

• CHADS2• https://www.mdcalc.com/chads2‐score‐atrial‐fibrillation‐stroke‐risk

•HAS‐BLED• https://www.mdcalc.com/has‐bled‐score‐major‐bleeding‐risk


Transitions

REMAP

Reframe “Given this information….”

Emotion “I can see you’re concerned…”, “Tell me more…”

Map future“Given this, what’s important..” “What are your concerns in the future…”

Align “It sounds like this is what’s important….”

Plan “This is what we can do…”

VitalTalk 2017


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Core idea

• Build rapport•Gather information


Framework

• Identify patient• Estimate prognosis

•Define goal• Value

• Plan of care• “Strong opinions, lightly held”


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Questions:[email protected]: @equijada


e quijada - im symposium sept 2017 - approved - 9-1-17 · 9/12/2017 1 palliative careupdate:...

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